Respite Night
7/29/23
MUHSEN HQ: 2605 W22nd Street, Suite 25, Oakbrook IL
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Name of Caregiver *
Phone Number of Caregiver *
Emergency contact phone number *
Name of person attending respite night? *
Disability of person attending respite night? *
Age of person attending respite night? *
gender of person attending respite night? *
Do they have some kind of supportive device? If they do, what is it? *
What is their best mode of communication? *
What do they find challenging? *
What do they find upsetting? *
What are the challenging behaviors we are likely to see when they are upset? *
How should one calm a negative behavior? *
Do they exhibit self injurious activities? Why? How can they be stopped?
What are their preferred activities? *
What are some strengths of theirs that we can build on? *
List any dietary restrictions for them? Do they have any allergies? Any food sensitivities/texture sensitivities *
List any applicable information for toileting *
Is there any additional information you would like to share?
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